- Email: [email protected]
Transcatheter occlusion of native persistent ductus arteriosus using conventional Gianturco coils
13. Munger MA, Johson B, Amber JJ, Callahan KS, Gilbert EM. Circulating concentrations of pminthunmatory cytokhtes in mild or moderate heart failure secondary to ischemic or ideopathic dilated cardiomyopathy. Am J Cardiol 1996;17:123-721. 14. Yan SF, Tritto I, Pinsky D, Liao H, Huang J, Fuller G, Brett J, May L, Stem D. Induction of interleukind (IL-6) by hypoxia in vascular cells. J Eiol
C/rem 1995;270:11463-11471. 15. Munger MA, StanekEJ, Nara AR, Stmbl KP, Decker MJ, Nair RN. Arterial oxygen saturation in chronic congestive heart failure. Am J Cardiol 1994;73:180-185. 16. Klein CL, Kohler H, Bittinger F, Otto M, Hermanns I, Kirkpatrick CJ. Comparative studieson vascular endothelium in vitro. 2. Hypoxia: its influences on endothelial cell proliferation and expression of cell adhesionmolecules. Pathobiology 1995;63:1-8.
Transcatheter AHeriosus
17. EggesboJB, Hjermann I, Lund PK, Joo GB, Gvstebo R, Kierulf P. LPSinduced release of E-1 beta, B-6, E-8, TNF-alpha and sCD14 in whole blood and PBMC from persons with high or low levels of HDL-lipopmtein. Cytokine 1994;6:521-529. 18. Dzau VJ, Packer M, Lilly LS, Swarm SL, Holler&erg NK, Williams GH. Prostaglandinsin severe congestive heart failure: relation to activation of the renin-angiotensin systemand hyponatremia.N EngZ J Med 1984;310:347-352. 19. Rem H, Gong J-H, Schmidt A, Nain M, GemsaD. Releaseof tumor necrosis factor-n from macrophages:enhancementand suppressionare dose-dependently regulated by prostaglandin % and cyclic nucleotides. J Zmnranol 1988;141:2388-2393. 20. Torre-Amione G, Kapadia S, Lee J, Durand J-B, Bies RD, Young JB, Mann DL. Tumor necrosis factor-o and tumor necrosis factor receptors in the failing human heart. Circulation 1996;93:704-711.
Occlusion of Native Persistent Usins Conventional eianturco
Ductus Coils
Mazeni Alwi, MRCP, Lim M. Kang, MRCP, Hasri Samion, MD, Haifa A. Latiff, MD, Geetha Kandavel, MRCP, and Robayaah Zambahari, FRCP
r
anscatheterclosure of small- to moderate-sized Gianturco coils (Cook, Bloomington, Indiana) 5 persistent ductus arteriosus (PDA) is well estab- cm long and with helical diametersof 5 mm or 8 mm lished as a procedure of first choice in many insti- were used. The following guideline was used in detutions. The Rashkind double umbrella device has termining the number of coils in relation to ductal been the most widely used and evaluated.le3 The size: 1 coil for ductuses < 1.5 mm, 2 coils for 1.6 to Gianturco coil has been in clinical use for 2 decadesB4 2.5 mm, 3 coils for 2.6 to 3.5 mm, 4 coils for 3.6 to However, its application for the closure of PDA is 4.0 mm, and r5 coils for ductuses >4.0 mm, taking comparatively recent. Although it is not specifically into consideration an exponential increase in crossdesigned for this purpose, and hence the variations sectional area for a given increase in diameter. Acin technique, its immediate and short-term results cordingly, 1 to 5 4Fr multipurpose catheters were have been encouraging.‘-’ We describe our experi- placed simultaneously across the ductus, 1 catheter ence in transcatheter closure of native PDA trans- for each coil. The coils were deployed as in a prevenously using Gianturco coils in 211 patients. viously described technique.’ In casesrequiring mul... tiple coils, the terminal 0.5 to 1.0 cm of each coil Between December 1994 and July 1996, 211 pa- was kept within the cathetersin the pulmonary artery tients with native PDA who had continuous murmurs and final deployment was carried out sequentially were subjected to this procedure. The median age once the coil’s position was deemedstable. This was and weight were 4.3 years (range 0.6 to 36.0) and to facilitate retrieval if the loops of coil deployed on 14.0 kg (range 5.1 to 53.0). One patient with addi- the aortic end slipped through the ductus. As far as tional pulmonary valve stenosisunderwent PDA oc- possible, only l/2 to 3/4 of a loop was deployed on clusion at the same time following successful pul- the pulmonary end of the ductus and the major pormonary valvuloplasty, and another has severefactor tion of the coil was seatedwithin the ampulla to minXII deficiency. The procedure was performed under imize left pulmonary artery stenosis. A repeat degeneral anesthesiain the smaller children. The nar- scending aortogram was performed 10 minutes after rowest internal diameter of the ductus was measured the procedure. In the rare casesof significant residual on the lateral projection of the descending aorto- shunt, the ductus was recrossed anterogradely, or if gram. Depending on the number of coils to be de- this was not possible, retrogradely, and additional ployed, 1 to 5 4Fr sheathswere inserted in the fem- coils were deployed. Clinical and Doppler echocaroral veins (up to 3 sheaths per vein). No patients diography evaluation to detect residual shunt and to were excluded on the basis of ductal morphology. measureleft pulmonary artery and descending aortic Ductuses >5.0 mm were excluded. The technique velocities were performed at 24 hours after the prodescribed below evolved during the initial learning cedure and serially at 3,6,12, and 18 months followcurve of 25 patients and was adhered to thereafter up. An option for reocclusion was put forward if residual shunt remained at 6 months. During the for the rest of the series. study period, 2 11 patients were subjectedto this procedure. For the entire series, procedural failure occurred in 7 patients (3%), 6 of them in the initial From the National Heart Institute, Kuala Lumpur, Malaysia. Dr. Alwi’s learning curve of the first 25 patients. In these 6 paaddress is: Department of Cardiology, National Heart Institute, 145, tients simultaneous multiple catheter technique was Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia. Manuscript re not used and only the smaller 5-mm diameter coils ceived October 8, 1996; revised manuscript received and accepted January 29, 1997. were deployed, resulting in slippage into the pul1430
0 1997 by Excerpta Medico, All rights reserved.
Inc.
0002-9149/97/$17.00 PII SOOO2-9149(97)00160-4
FIGURE 1. Three 4Fr multipurpose catheters passed transvenous , almost oc&ding the t uctus. A, the first coil is partially extruded. 6, ihree p&tially deokwed . , coils seated in the ductal ampulla with a short segmeni of each coil still within the catheters in the pulmonary arte C, coils completely dep7 oyed with only a short segment on the pulmonary s-de.
monary artery. They were successfully retrieved and the Rashkind umbrella device was successfully implanted in each. Two patients who had audible residud shunt and for geographical reasons could not return for follow-up evaluation underwent early reocclusion 3 days after the first to effect complete closure. Five patients were lost to follow-up, 3 of whom had complete occlusion, and 2 who had trivial residual shunt at 24 hours assessment.A total of 197 patients were analyzed. The mean PDA size was 2.3 & 0.7 mm. The mean screening time was 14.8 minutes (range 3.7 to 100). A total of 495 coils were implanted, of which 69% were 8-mm in diameter; the rest were 5 mm. Forty patients (20%) had 1 coil implanted, 57 had 2 coils (29%), 70 had 3 coils (35%), 19 had 4 coils (lo%), and 11 had 5 coils (6%), with a mean of 2.5 + 1.1 coils per patient. Small residual shunt was noted in 81 patients (41%) on angiography. At 24 hours complete occlusion was noted in 158 patients (80%). Of 151 patients at 3month follow-up, complete occlusion was noted in 138 (91%). One hundred eighteen patients had a minimum follow-up of 6 months and complete occlusion was noted in 111 (94%). All residual shunts detected by color Doppler were silent except in 3 (patients 6, 9, and 37); 2 were systolic and 1 continuous. These 3 patients subsequently underwent a reocclusion procedure at 8 months to effect complete occlusion. Fifty-six patients had a minimum of 12 months follow-up, including the 3 above who underwent reocclusion. Of these, 1 patient (2%) had detectable residual shunt on color Doppler only. Without a second procedure, 7% would have residual shunt at l-year follow-up. In 22 patients, 33 coils were retrieved, mainly because of slippage of extruded loops of coils during catheter withdrawal through the ductus into the pulmonary artery. Seven coils embolized to the peripheral pulmonary artery and they were successfully retrieved. Five patients (2%) had mild left pulmonary artery stenosis, defined as having peak velocity >2.0 m/s, the maximum being 2.5 m/s. None of the patients had descending aortic velocity of > 1.4 m/s. There were no other late adverse events. ... This technique was initially described for closure of very small ductuses.6*‘oThe results in,subsequent
series have shown that the efficacy and safety of this technique compare favorably with that of the Rashkind occluder device.7-9 Procedural failures early in our series took place before the use of simultaneous multiple catheter techniques and exclusive use of 5mm diameter coils, which resulted in coil migrations. With the transvenous approach it is possible to have up to 5 4Fr catheters placed simultaneously across the ductus to prevent coil migration by almost occluding it; this provides better control to deploy only a short length of coil on the pulmonary side to minimize left pulmonary artery stenosis. To minimize the risk of peripheral embolization, we recommend leaving 0.5 to 1.0 cm of the coil within the catheters before final deployment to facilitate retrieval ,should coil slippage into the pulmonary artery occur. Lack of a controlled-release mechanism seems to be the chief disadvantage of the Gianturco coils. Toward this end, the purpose designed controlled-release PDA coils (William Cook Europe AlS, Bjaeverskov, Denmark) have been recently introduced to overcome this problem. However, this has not completely eliminated embolization of coils to the peripheral pulmonary arteries.’ ’ Compared with the previous series, we tended to use more. coils for a particular PDA size. Only 20% received 1 coil, because this is usually reserved for ductuses < 1.5 mm, whereas 5 1% received r3 coils. Mild left pulmonary artery stenosis is seen in 2% of patients despite taking precautions to allow only a short portion of the coil on the pulmonary end of the ductus, echoing the experience with the Rashkind occluder device.‘* It would be prudent to continue endocarditis prophylaxis in these patients. Given the appropriate number of coils used for a particular PDA size, most residual shunts seen at 24 hours after deployment are trivial and will close spontaneously over 3 to 6 months. Its much lower cost compared with surgical ligation or other purpose-designed devices makes it an attractive option. Our short-term results suggests that transcatheter closure of PDA with the Gianturco coil is safe and efficacious. However, caution should be exercised in their use in sm,all children who require multiple coils in view of the potential complication of left pulmonary artery stenosis. BRIEF REPORTS 1431
1. Hosking MC, BensonLN, Musewe NN, Dyck JD, Freedom RM. Transcatheter occlusion of the persistently patent ductus arteriosus occluder: forty-month follow up andprevalenceof residual shunting.Circulation 1991;84:2313-2317. 2. Khan MA, Yousef SA, Mullins CE, Sawyer W. Experience with 205 proceduresof transcatheterclosure of ductusarteriosusin 182patients,with special reference to residual shuntsand long term follow up. J Thorac Cardiovmc Surg 1992;104:1721-1727. 3. Latson LA, Hofschire PJ, Kugler JD, CheathamJP, Gumbiner CH, Danford DA. Transcatheter closure of patent ductus arteriosus in pediatric patients. J Pediatr 1989;115:549-553. 4. Gianturco C, Anderson JH, Wallace S. Mechanical devices for arterial occlusion. Am J Radio1 1975;124:428-435. 5. Llyod TR, Fedderly R, Mendelsohn AM, Sandhu SK, B&man RH III. Transcatheterocclusion of natent ductus arteriosus with Gianturco coils. Circulation 1993;88:1412-14iO. aMooleJW,GeorgeL,~kSEUathewson~,SpicerRL,U~K,Roth&ureofthesmau@ent man& CambierP.i, Slacktic, Kirby WC. Percutaneous ductusarteriosususingx&ding springcoils.J Am CoUCar& 1994,23:75%765.
7. Hijazi ZM, Geggel RL. Results of anterogradetranscatheterclosure of patent ductus arteriosus using single or multiple Gianturco coils: immediate and short term results. Am J Cardiol 1994;74:925-929. 8. Galal 0, De Mour M, Al Fadley F, Hijazi ZM. Transcatheterclosure of the patent ductusarteriosus: comparisonbetween the Rashkind occluder device and the antegradeGianturco coils technique.Am Hem J 1996;131:368-372. 9. Shim D, Fedderly RT, Be&man RH III, Ludomirsky A, Young ML, Schork MA, Lloyd TR. Follow up of coil occlusion of patent ductus arteriosus. J Am Cdl Cardiol 1996;28:207-211. 10. Cambier PA, Kirby WC, Wortham DC, Moore JW. Percutaneousclosure of the small (< 2.5 mm) patent ductus artcriosus using coil embolization. Am J Cardiol 1992;69:815-816. 11. Tometzki AJP, Walsh KP, Arnold R, Peart I, Bu’lock FA, Snxram N, Abdulhamed JM, Godman MJ. Tramcatheter occlusion of the patent ductus arteriosus with Cook detachablecoils. Cardiol Young 1996;6(suppll):S6. 12. Fadley R, Halees Z, Galal 0, Kumar N, Wilson N. Left pulmonary artery stenosis:seriouscomplication of transcatheterocclusion of the persistentarterial duct (lett). Lancet 1993;341:559-560.
AssociatCon Between Plasma Homocysteine Extracranial Carotid Arterial Disease in Older Wilbert
S. Aronow,
lasma homocysteine is a risk factor for arteriosclerotic vasP cular disease.’ Selhub et al2 reported
MD, Chul Ahn, PhD, and Myron
TABLE I Association Between and 40% to 100% Extracroniol
R. Schoenfeld,
and Persows MD
Plasma Homocysteine, Vitamin 812, and Foiate Levels Corotid Arterial Disease (ECAD) in 12 1 Older Men
40% to 100% ECXD 0% to 39% ECAD in 418 older men and 623 older (n = 99) p Value (n = 22) women in the Framingham Heart a0 -c 9 NS 81 +8 Study that plasma homocysteine Age b) Homocysteine (pmol/L) 1926 1424 .0.003 was a risk factor for extracranial caVitamin 812 (rig/L) 454 + 215 553 + 154 0.052 rotid arterial disease (ECAD). We Folote (/lg/L) 6.3 + 2.1 9.5 + 3.2 0.0001 are reporting data showing an asIncreased homocysteine 1 o/22 (45%) 20/99 (20%) 0.013 (> 17 pmol/L) sociation between plasma homocysLow or indeterminate vitamin 812 3/22 (14%) 2/99 (2%) 0.041 teine level and 40% to 100% ECAD (<200 rig/L) in 121 older men and 279 older women in a long-term health care facility. 80% to 99% reduction; and V,, 0 m/s (no Doppler ... signal on ~2 separate tests) = 100% reduction. We investigated, in a prospective study, the asBlood was drawn in the fasting state from 400 sociation between plasma homocysteine, vitamin persons to determine plasma vitamin B12 and folate B12,and folate levels with the prevalence of 40% to levels by SmithKline Beecham Clinical Laborato100% ECAD detected by bilateral carotid duplex ul- ries, Inc. (Syosset, New York) and to determine trasonograms in 121 men and 279 women (mean age plasma homocysteine levels by Specialty Laborato81 + 8 years; range 60 to 99) in a long-term health ries, Inc. (Santa Monica, California). No patient was care facility. Bilateral carotid duplex ultrasonograms in renal failure or was taking phenytoin, carbamawere obtained as previously described with an Inter- zepine, colestipol, niacin, isoniazide, or hydralazine. spec XL machine (Interspec Inc., Reedsville, Penn- Plasma vitamin B12 and folate levels were detersylvania) using a 7.5MHz transducer with combined mined by using the Abbott IMx B12 assay and the 2-dimensional, real-time, and pulsed or high-pulse Abbott IMx folate assay (Abbott Diagnostics, Abbott frequency Doppler capabilities.3 The severity of in- Park, Illinois)? Plasma homocysteine levels were deternal or common carotid atherosclerotic obstruction termined by a high-performance liquid chromatogwas semiquantified by using conventional Doppler raphy assay.5 Normal plasma homocysteine levels criteria: maximal velocity (V,,) ~0.8 m/s = ~40% are 4.0 to 17.0 pmol/L. Normal plasma vitamin B12 arterial luminal diameter reduction; V,, 0.80 to 1.75 levels are >200 rig/L. Indeterminate plasma vitamin m/s = 40% to 80% reduction; V,, > 1.75 m/s = B12levels are 160 to 200 rig/L. Low plasma vitamin B12levels are < 160 rig/L. Normal plasma folate levels are 3 to 19 pg/L. For analyses comparing 2 From the Hebrew Hospital Home, Bronx, New York; the Department groups, Fisher’s exact or &i-square tests were apof Geriatrics and Adult Development, Mount Sinai School of Medicine, New ‘fork, New York; and the Division of Clinical Epidemiolplied to dichotomous variables, and Student’s t tests ogy, University of Texas Medical School at Houston, Houston, Texas. were used for continuous variables. Dr. Aronow’s address is: Hebrew Hospital Home, 801 Co-op City Tables I and II show the association between Boulevard, Bronx, New York 10475. Manuscript received October plasma homocysteine, vitamin B12, and folate levels, 3 1, 1996; revised manuscript received and accepted January 27, 1997. and 40% to 100% ECAD in 121 older men (Table I)
1432
o 1997 by Excerpta Medico, All rights reserved.
Inc.
0002-9149/97/Q 17.00 PII SOOO2.9149(97)00161-6
C/rem 1995;270:11463-11471. 15. Munger MA, StanekEJ, Nara AR, Stmbl KP, Decker MJ, Nair RN. Arterial oxygen saturation in chronic congestive heart failure. Am J Cardiol 1994;73:180-185. 16. Klein CL, Kohler H, Bittinger F, Otto M, Hermanns I, Kirkpatrick CJ. Comparative studieson vascular endothelium in vitro. 2. Hypoxia: its influences on endothelial cell proliferation and expression of cell adhesionmolecules. Pathobiology 1995;63:1-8.
Transcatheter AHeriosus
17. EggesboJB, Hjermann I, Lund PK, Joo GB, Gvstebo R, Kierulf P. LPSinduced release of E-1 beta, B-6, E-8, TNF-alpha and sCD14 in whole blood and PBMC from persons with high or low levels of HDL-lipopmtein. Cytokine 1994;6:521-529. 18. Dzau VJ, Packer M, Lilly LS, Swarm SL, Holler&erg NK, Williams GH. Prostaglandinsin severe congestive heart failure: relation to activation of the renin-angiotensin systemand hyponatremia.N EngZ J Med 1984;310:347-352. 19. Rem H, Gong J-H, Schmidt A, Nain M, GemsaD. Releaseof tumor necrosis factor-n from macrophages:enhancementand suppressionare dose-dependently regulated by prostaglandin % and cyclic nucleotides. J Zmnranol 1988;141:2388-2393. 20. Torre-Amione G, Kapadia S, Lee J, Durand J-B, Bies RD, Young JB, Mann DL. Tumor necrosis factor-o and tumor necrosis factor receptors in the failing human heart. Circulation 1996;93:704-711.
Occlusion of Native Persistent Usins Conventional eianturco
Ductus Coils
Mazeni Alwi, MRCP, Lim M. Kang, MRCP, Hasri Samion, MD, Haifa A. Latiff, MD, Geetha Kandavel, MRCP, and Robayaah Zambahari, FRCP
r
anscatheterclosure of small- to moderate-sized Gianturco coils (Cook, Bloomington, Indiana) 5 persistent ductus arteriosus (PDA) is well estab- cm long and with helical diametersof 5 mm or 8 mm lished as a procedure of first choice in many insti- were used. The following guideline was used in detutions. The Rashkind double umbrella device has termining the number of coils in relation to ductal been the most widely used and evaluated.le3 The size: 1 coil for ductuses < 1.5 mm, 2 coils for 1.6 to Gianturco coil has been in clinical use for 2 decadesB4 2.5 mm, 3 coils for 2.6 to 3.5 mm, 4 coils for 3.6 to However, its application for the closure of PDA is 4.0 mm, and r5 coils for ductuses >4.0 mm, taking comparatively recent. Although it is not specifically into consideration an exponential increase in crossdesigned for this purpose, and hence the variations sectional area for a given increase in diameter. Acin technique, its immediate and short-term results cordingly, 1 to 5 4Fr multipurpose catheters were have been encouraging.‘-’ We describe our experi- placed simultaneously across the ductus, 1 catheter ence in transcatheter closure of native PDA trans- for each coil. The coils were deployed as in a prevenously using Gianturco coils in 211 patients. viously described technique.’ In casesrequiring mul... tiple coils, the terminal 0.5 to 1.0 cm of each coil Between December 1994 and July 1996, 211 pa- was kept within the cathetersin the pulmonary artery tients with native PDA who had continuous murmurs and final deployment was carried out sequentially were subjected to this procedure. The median age once the coil’s position was deemedstable. This was and weight were 4.3 years (range 0.6 to 36.0) and to facilitate retrieval if the loops of coil deployed on 14.0 kg (range 5.1 to 53.0). One patient with addi- the aortic end slipped through the ductus. As far as tional pulmonary valve stenosisunderwent PDA oc- possible, only l/2 to 3/4 of a loop was deployed on clusion at the same time following successful pul- the pulmonary end of the ductus and the major pormonary valvuloplasty, and another has severefactor tion of the coil was seatedwithin the ampulla to minXII deficiency. The procedure was performed under imize left pulmonary artery stenosis. A repeat degeneral anesthesiain the smaller children. The nar- scending aortogram was performed 10 minutes after rowest internal diameter of the ductus was measured the procedure. In the rare casesof significant residual on the lateral projection of the descending aorto- shunt, the ductus was recrossed anterogradely, or if gram. Depending on the number of coils to be de- this was not possible, retrogradely, and additional ployed, 1 to 5 4Fr sheathswere inserted in the fem- coils were deployed. Clinical and Doppler echocaroral veins (up to 3 sheaths per vein). No patients diography evaluation to detect residual shunt and to were excluded on the basis of ductal morphology. measureleft pulmonary artery and descending aortic Ductuses >5.0 mm were excluded. The technique velocities were performed at 24 hours after the prodescribed below evolved during the initial learning cedure and serially at 3,6,12, and 18 months followcurve of 25 patients and was adhered to thereafter up. An option for reocclusion was put forward if residual shunt remained at 6 months. During the for the rest of the series. study period, 2 11 patients were subjectedto this procedure. For the entire series, procedural failure occurred in 7 patients (3%), 6 of them in the initial From the National Heart Institute, Kuala Lumpur, Malaysia. Dr. Alwi’s learning curve of the first 25 patients. In these 6 paaddress is: Department of Cardiology, National Heart Institute, 145, tients simultaneous multiple catheter technique was Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia. Manuscript re not used and only the smaller 5-mm diameter coils ceived October 8, 1996; revised manuscript received and accepted January 29, 1997. were deployed, resulting in slippage into the pul1430
0 1997 by Excerpta Medico, All rights reserved.
Inc.
0002-9149/97/$17.00 PII SOOO2-9149(97)00160-4
FIGURE 1. Three 4Fr multipurpose catheters passed transvenous , almost oc&ding the t uctus. A, the first coil is partially extruded. 6, ihree p&tially deokwed . , coils seated in the ductal ampulla with a short segmeni of each coil still within the catheters in the pulmonary arte C, coils completely dep7 oyed with only a short segment on the pulmonary s-de.
monary artery. They were successfully retrieved and the Rashkind umbrella device was successfully implanted in each. Two patients who had audible residud shunt and for geographical reasons could not return for follow-up evaluation underwent early reocclusion 3 days after the first to effect complete closure. Five patients were lost to follow-up, 3 of whom had complete occlusion, and 2 who had trivial residual shunt at 24 hours assessment.A total of 197 patients were analyzed. The mean PDA size was 2.3 & 0.7 mm. The mean screening time was 14.8 minutes (range 3.7 to 100). A total of 495 coils were implanted, of which 69% were 8-mm in diameter; the rest were 5 mm. Forty patients (20%) had 1 coil implanted, 57 had 2 coils (29%), 70 had 3 coils (35%), 19 had 4 coils (lo%), and 11 had 5 coils (6%), with a mean of 2.5 + 1.1 coils per patient. Small residual shunt was noted in 81 patients (41%) on angiography. At 24 hours complete occlusion was noted in 158 patients (80%). Of 151 patients at 3month follow-up, complete occlusion was noted in 138 (91%). One hundred eighteen patients had a minimum follow-up of 6 months and complete occlusion was noted in 111 (94%). All residual shunts detected by color Doppler were silent except in 3 (patients 6, 9, and 37); 2 were systolic and 1 continuous. These 3 patients subsequently underwent a reocclusion procedure at 8 months to effect complete occlusion. Fifty-six patients had a minimum of 12 months follow-up, including the 3 above who underwent reocclusion. Of these, 1 patient (2%) had detectable residual shunt on color Doppler only. Without a second procedure, 7% would have residual shunt at l-year follow-up. In 22 patients, 33 coils were retrieved, mainly because of slippage of extruded loops of coils during catheter withdrawal through the ductus into the pulmonary artery. Seven coils embolized to the peripheral pulmonary artery and they were successfully retrieved. Five patients (2%) had mild left pulmonary artery stenosis, defined as having peak velocity >2.0 m/s, the maximum being 2.5 m/s. None of the patients had descending aortic velocity of > 1.4 m/s. There were no other late adverse events. ... This technique was initially described for closure of very small ductuses.6*‘oThe results in,subsequent
series have shown that the efficacy and safety of this technique compare favorably with that of the Rashkind occluder device.7-9 Procedural failures early in our series took place before the use of simultaneous multiple catheter techniques and exclusive use of 5mm diameter coils, which resulted in coil migrations. With the transvenous approach it is possible to have up to 5 4Fr catheters placed simultaneously across the ductus to prevent coil migration by almost occluding it; this provides better control to deploy only a short length of coil on the pulmonary side to minimize left pulmonary artery stenosis. To minimize the risk of peripheral embolization, we recommend leaving 0.5 to 1.0 cm of the coil within the catheters before final deployment to facilitate retrieval ,should coil slippage into the pulmonary artery occur. Lack of a controlled-release mechanism seems to be the chief disadvantage of the Gianturco coils. Toward this end, the purpose designed controlled-release PDA coils (William Cook Europe AlS, Bjaeverskov, Denmark) have been recently introduced to overcome this problem. However, this has not completely eliminated embolization of coils to the peripheral pulmonary arteries.’ ’ Compared with the previous series, we tended to use more. coils for a particular PDA size. Only 20% received 1 coil, because this is usually reserved for ductuses < 1.5 mm, whereas 5 1% received r3 coils. Mild left pulmonary artery stenosis is seen in 2% of patients despite taking precautions to allow only a short portion of the coil on the pulmonary end of the ductus, echoing the experience with the Rashkind occluder device.‘* It would be prudent to continue endocarditis prophylaxis in these patients. Given the appropriate number of coils used for a particular PDA size, most residual shunts seen at 24 hours after deployment are trivial and will close spontaneously over 3 to 6 months. Its much lower cost compared with surgical ligation or other purpose-designed devices makes it an attractive option. Our short-term results suggests that transcatheter closure of PDA with the Gianturco coil is safe and efficacious. However, caution should be exercised in their use in sm,all children who require multiple coils in view of the potential complication of left pulmonary artery stenosis. BRIEF REPORTS 1431
1. Hosking MC, BensonLN, Musewe NN, Dyck JD, Freedom RM. Transcatheter occlusion of the persistently patent ductus arteriosus occluder: forty-month follow up andprevalenceof residual shunting.Circulation 1991;84:2313-2317. 2. Khan MA, Yousef SA, Mullins CE, Sawyer W. Experience with 205 proceduresof transcatheterclosure of ductusarteriosusin 182patients,with special reference to residual shuntsand long term follow up. J Thorac Cardiovmc Surg 1992;104:1721-1727. 3. Latson LA, Hofschire PJ, Kugler JD, CheathamJP, Gumbiner CH, Danford DA. Transcatheter closure of patent ductus arteriosus in pediatric patients. J Pediatr 1989;115:549-553. 4. Gianturco C, Anderson JH, Wallace S. Mechanical devices for arterial occlusion. Am J Radio1 1975;124:428-435. 5. Llyod TR, Fedderly R, Mendelsohn AM, Sandhu SK, B&man RH III. Transcatheterocclusion of natent ductus arteriosus with Gianturco coils. Circulation 1993;88:1412-14iO. aMooleJW,GeorgeL,~kSEUathewson~,SpicerRL,U~K,Roth&ureofthesmau@ent man& CambierP.i, Slacktic, Kirby WC. Percutaneous ductusarteriosususingx&ding springcoils.J Am CoUCar& 1994,23:75%765.
7. Hijazi ZM, Geggel RL. Results of anterogradetranscatheterclosure of patent ductus arteriosus using single or multiple Gianturco coils: immediate and short term results. Am J Cardiol 1994;74:925-929. 8. Galal 0, De Mour M, Al Fadley F, Hijazi ZM. Transcatheterclosure of the patent ductusarteriosus: comparisonbetween the Rashkind occluder device and the antegradeGianturco coils technique.Am Hem J 1996;131:368-372. 9. Shim D, Fedderly RT, Be&man RH III, Ludomirsky A, Young ML, Schork MA, Lloyd TR. Follow up of coil occlusion of patent ductus arteriosus. J Am Cdl Cardiol 1996;28:207-211. 10. Cambier PA, Kirby WC, Wortham DC, Moore JW. Percutaneousclosure of the small (< 2.5 mm) patent ductus artcriosus using coil embolization. Am J Cardiol 1992;69:815-816. 11. Tometzki AJP, Walsh KP, Arnold R, Peart I, Bu’lock FA, Snxram N, Abdulhamed JM, Godman MJ. Tramcatheter occlusion of the patent ductus arteriosus with Cook detachablecoils. Cardiol Young 1996;6(suppll):S6. 12. Fadley R, Halees Z, Galal 0, Kumar N, Wilson N. Left pulmonary artery stenosis:seriouscomplication of transcatheterocclusion of the persistentarterial duct (lett). Lancet 1993;341:559-560.
AssociatCon Between Plasma Homocysteine Extracranial Carotid Arterial Disease in Older Wilbert
S. Aronow,
lasma homocysteine is a risk factor for arteriosclerotic vasP cular disease.’ Selhub et al2 reported
MD, Chul Ahn, PhD, and Myron
TABLE I Association Between and 40% to 100% Extracroniol
R. Schoenfeld,
and Persows MD
Plasma Homocysteine, Vitamin 812, and Foiate Levels Corotid Arterial Disease (ECAD) in 12 1 Older Men
40% to 100% ECXD 0% to 39% ECAD in 418 older men and 623 older (n = 99) p Value (n = 22) women in the Framingham Heart a0 -c 9 NS 81 +8 Study that plasma homocysteine Age b) Homocysteine (pmol/L) 1926 1424 .0.003 was a risk factor for extracranial caVitamin 812 (rig/L) 454 + 215 553 + 154 0.052 rotid arterial disease (ECAD). We Folote (/lg/L) 6.3 + 2.1 9.5 + 3.2 0.0001 are reporting data showing an asIncreased homocysteine 1 o/22 (45%) 20/99 (20%) 0.013 (> 17 pmol/L) sociation between plasma homocysLow or indeterminate vitamin 812 3/22 (14%) 2/99 (2%) 0.041 teine level and 40% to 100% ECAD (<200 rig/L) in 121 older men and 279 older women in a long-term health care facility. 80% to 99% reduction; and V,, 0 m/s (no Doppler ... signal on ~2 separate tests) = 100% reduction. We investigated, in a prospective study, the asBlood was drawn in the fasting state from 400 sociation between plasma homocysteine, vitamin persons to determine plasma vitamin B12 and folate B12,and folate levels with the prevalence of 40% to levels by SmithKline Beecham Clinical Laborato100% ECAD detected by bilateral carotid duplex ul- ries, Inc. (Syosset, New York) and to determine trasonograms in 121 men and 279 women (mean age plasma homocysteine levels by Specialty Laborato81 + 8 years; range 60 to 99) in a long-term health ries, Inc. (Santa Monica, California). No patient was care facility. Bilateral carotid duplex ultrasonograms in renal failure or was taking phenytoin, carbamawere obtained as previously described with an Inter- zepine, colestipol, niacin, isoniazide, or hydralazine. spec XL machine (Interspec Inc., Reedsville, Penn- Plasma vitamin B12 and folate levels were detersylvania) using a 7.5MHz transducer with combined mined by using the Abbott IMx B12 assay and the 2-dimensional, real-time, and pulsed or high-pulse Abbott IMx folate assay (Abbott Diagnostics, Abbott frequency Doppler capabilities.3 The severity of in- Park, Illinois)? Plasma homocysteine levels were deternal or common carotid atherosclerotic obstruction termined by a high-performance liquid chromatogwas semiquantified by using conventional Doppler raphy assay.5 Normal plasma homocysteine levels criteria: maximal velocity (V,,) ~0.8 m/s = ~40% are 4.0 to 17.0 pmol/L. Normal plasma vitamin B12 arterial luminal diameter reduction; V,, 0.80 to 1.75 levels are >200 rig/L. Indeterminate plasma vitamin m/s = 40% to 80% reduction; V,, > 1.75 m/s = B12levels are 160 to 200 rig/L. Low plasma vitamin B12levels are < 160 rig/L. Normal plasma folate levels are 3 to 19 pg/L. For analyses comparing 2 From the Hebrew Hospital Home, Bronx, New York; the Department groups, Fisher’s exact or &i-square tests were apof Geriatrics and Adult Development, Mount Sinai School of Medicine, New ‘fork, New York; and the Division of Clinical Epidemiolplied to dichotomous variables, and Student’s t tests ogy, University of Texas Medical School at Houston, Houston, Texas. were used for continuous variables. Dr. Aronow’s address is: Hebrew Hospital Home, 801 Co-op City Tables I and II show the association between Boulevard, Bronx, New York 10475. Manuscript received October plasma homocysteine, vitamin B12, and folate levels, 3 1, 1996; revised manuscript received and accepted January 27, 1997. and 40% to 100% ECAD in 121 older men (Table I)
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